At press time, HCAC has learned that Kathy Hobden, Health Care Benefits Section, Division of Health Plan Management, is writing rules which would: 
1. Create “normative standards” (NORMS) for home health aide, personal care provider and homemaker services, and 
2. Require home health aide services to be billed in 30 minute units rather than by the visit. It is expected that provider agencies will be paid just $13 for each 30 minutes of service provided. 

According to Hobden, the rules will be distributed to the home care community in mid-August and will be presented to the State Board of Medical Services on September 10th at the Ramada Inn, I-76 and East Hwy 6 in Sterling, Colorado (970) 835-7275. An 8 a.m. continental breakfast is open to the public and the meeting begins at 9 a.m. Persons wishing to testify or present written statements to the Board should call Deborah Collette at (303) 866-4416 for details. 

These proposals are the department’s answer to a continuing trend of increased utilization (services provided per client) in the home health and HCBS programs. Extensive studies were conducted by the department and reports written for the legislature in both October 1997 and October 1998. As reported in previous issues of the management report, the state legislature has been critical of the 25 to 40 percent increase in utilization in the programs, even in light of the $35 million per year in savings resulting from hospital and nursing home avoidance. 

In the legislature’s attempt to address this issue, this year’s Long Appropriations Bill (SB 99-215) which dictates state government spending for Fiscal Year 1999-2000, requires the department to: 

- “make specific recommendations on limiting utilization in the HCBS waiver program” by October 15, 1999, and 
- “report on the growth in the home health program, on its efforts to contain the growth in the home health program, and the fiscal impact of its recommendations made to the Joint Budget Committee regarding this program in FY 1998-99.” 

More on “NORMS” 

The first proposal to be considered by the State Board in September will require case managers and home care providers to follow normative standards which define each task such as bathing, ambulation, transfers and dressing/undressing. The NORMS state how long it should take to perform a task and how frequently the task should be done. 

HCAC Position: 
HCAC has opposed the proposal as written and has recommended that NORMS should be simply guidelines for case managers to use as one tool to justify the authorized hours to the HCBS client; for home care providers in knowing how long tasks should be taking their employees to complete on the average; and for post pay reviewers to refer to when they have identified suspected abuse of the regulations. HCAC recommended that there be an incentive payment for HCBS case managers when documentation supports the fact that prior authorization revisions are necessary. 

HCAC also opposed the department mandating new, standardized forms. The department has agreed. HCAC also recommended that the department use mechanisms currently in place such as survey and post pay review to enforce regulations which may be abused by providers. 

More on 30 minute units 

The department believes that paying by the unit will reward agencies that provide longer visits and will discourage ultra short visits and unbundling of home health aide and HCBS personal care visits. Under the new proposed reimbursement system, agencies could send in a personal care provider to provide the personal care/homemaking services immediately following a one-hour home health aide visit and bill for both based on the time spent. (This practice violates current rules because the home health aide is supposed to provide all services that can be accomplished in a 21/2 hour visit.) 

HCAC Position: HCAC has told the department that $13 will not cover the overhead costs associated with scheduling, supervising and billing for a 30-minute home health aide visit. HCAC has urged the department to “front-load” the reimbursement rate to make it worthwhile to provide the shorter visit when appropriate. 

~ Ellen Caruso, Executive Director (ecaruso@assnoffice.com)

The association’s Legislative/Advocacy Council and lobbying team had an especially difficult time getting the increase this year because of several factors: 
 

~ The Taxpayers Bill of Rights Amendment (TABOR), also referred to as Amendment 1, continues to limit growth in spending to inflation plus population growth. This increase of about 5-6 percent is far below the expected growth in home care spending. 
~ Home health and HCBS utilization (visits per patient) went up by 25 to 40 percent for the third year in a row. Subsequently, the Joint Budget Committee voted to limit growth by 17.5 percent in FY 1999-2000. 
~ The Department of Health Care Policy’s request for a cost of living increase for home care providers was pulled off the table after the election of a new governor who required all departments to reduce 
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their budget requests by five percent. Once the department pulls a budget request, its staff members are not allowed to lobby for the funding. 
~ After the allocation was approved by the legislature to cover services across the board, the Department requested that the Joint Budget Committee direct all increases into one program. HCAC lobbied that even though several home care programs may have more need than others, the cost of living increase was needed by all services. The proposal was withdrawn. 

The HCAC Legislative/Advocacy Council, co-chaired by Dan Nicholson, Geriatric Services of America, Woodland Park, and Sue Brown, Argus of Colorado Home Health, Denver, monitored 60 of these bills and actively lobbied about a dozen. Most important to Colorado home care providers besides the annual appropriations bill which included a rate increase for home care services are the following bills: 

House Bill 99-1019 was introduced by Rep. Marcy Morrison (R-Manitou Springs) and Sen. Dottie Wham (R-Denver) and passed both houses on April 23rd. The bill makes permanent the Colorado Health Care Task Force made up of ten legislators who will gather information to formulate legislation if necessary for the proper operation of the health care system in Colorado. The task force shall consider: 

~ emerging trends in Colorado health care and their impacts on consumers; 
~ the effect of recent shifts in the way health care is delivered and paid for; 
~ the ability of consumers to obtain and keep adequate, affordable health insurance coverage, including coverage for catastrophic illnesses; 
~ the effect of managed care on the ability of consumers to obtain timely access to quality care; 
~ the operation of the program for the medically indigent; 
~ the future trends for health care coverage rates for employees and employers; 
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~ the role of public health programs and services; 
~ social and financial costs and benefits of mandated health care coverage; and 
~ costs and benefits of providing preventive care and early treatment for people with chronic illnesses who may eventually need long-term care. 

House Bill 99-1088 clarifies that insurance benefits available to newborn children shall include the coverage of all medically necessary care and treatment of medically diagnosed congenital defects and birth abnormalities for the first 31 days of the newborn’s life and requires each individual and group health plan to provide medically necessary physical, occupational and speech therapy for the care and treatment of a child’s congenital defects and birth abnormalities up to five years of age. The bill was sponsored by Rep. Marcy Morrison (R-Manitou Springs) and Sen. Stanley Matsunaka (D-Loveland). It passed both houses on April 26th. 

House Bill 99-1250, sponsored by Rep. Steve Johnson (R-Fort Collins) and Sen. Mary Ellen Epps (R-Colorado Springs), declares that unnecessary delays in the payment of routine and uncontested claims for reimbursement represent an unwarranted drain on health care providers’ resources and costs patients time and money. The bill requires health insurance entities to pay, deny or settle “clean” claims (i.e., those filed on the insurer’s standard form and containing all necessary information in accordance with the carrier’s published filing requirements) within 30 calendar days after receipt by the carrier if submitted electronically and within 45 calendar days after receipt by the carrier if submitted by any other means. The bill requires that all other claims be paid, denied, or settled within 90 calendar days after receipt, unless fraud is present. The bill passed both houses on April 27th. 

House Bill 99-1306, sponsored by Rep. Marcy Morrison (R-Colorado Springs) and Sen. Dottie Wham (R-Denver) declares that covered individuals should have access to independent external review of health care coverage decisions. The bill requires independent review entities to be certified by the commissioner of insurance who will be responsible for coordinating the external review process. The bill requires insurance plans to notify covered persons of the availability of the external review after internal review appeals have been exhausted and to pay the costs of such reviews. The Colorado Provider Coalition was successful in adding language to the bill which requires the insurance commissioner to consult with and utilize resources including health care providers in the development of the rules to accompany the legislation. Also added at the coalition’s request was language requiring expert reviewers to have “actual current” clinical experience. The bill passed both houses on May 3. 

House Bill 99-1311, sponsored by Rep. Lola Spradley (R-Beulah) and Sen. Dave Owen (R-Greeley), ensures a refund to businesses of 100 percent of the first $500 paid in business personal property tax in 1998. Any amount paid over $500 will be refunded at 13.37 percent. Form DR 1311, which must be completed correctly and postmarked by August 31, 1999, must include proper documentation of the tax paid in order to secure the tax refund. It is expected that 126,000 businesses will be eligible for this refund. Call the Dept. of Revenue at (303) 232-1416 for information. 

Colorado’s 100 state legislators have gone home for now. But their work is not done. They will be meeting with constituents; chairing town hall meetings; having fund raisers and planning their re-election campaigns in Year 2000. This is the ideal time for you to call your state representative and senator and invite him or her to visit your agency or to have coffee at your local gathering spot. Now is the time to explain what home care is and what you and your staff do each and every day of your life! And be sure to ask what your legislator is interested in and offer to help with those issues as well as your own. 

DON’T FORGET! DO NOT WAIT ANOTHER DAY TO MAKE THAT CALL TO YOUR STATE LEGISLATOR.  

~~ Ellen Caruso, Executive Director (ecaruso@assnoffice.com)

~ eliminate the 15 percent cut in Medicare home health spending scheduled for October 1, 2000; 
~ increase payments under the interim payment system (IPS) for agencies serving high-cost, medically complex patients; 
~ increase the per visit reimbursement limits form 106 percent of the median to 108 percent; 
~ increase the per beneficiary reimbursement limits under IPS for agencies with limits below the national average; 
~ provide for a 36-month interest-free repayment period for recovery of overpayments resulting from IPS per beneficiary limits; 
~ eliminate the 15-minute reporting requirement; 
~ require surety bonds be used only to protect against fraudulent claims, not overpayments, and 
~ extend the periodic interim payment program for 12 months following the implementation of a prospective payment system. 

The Medicare Home Health Services Equity Act of 1999 was introduced by Rep. J. C. Watts and Wes Watkins, both Republicans from Oklahoma serving on key committees. The bill is designed to provide greater equity to the Medicare home health benefit and ensure access to necessary home health services furnished in an efficient manner.  The legislation embodies most of the provisions needed for comprehensive reform identified by all the national home health organizations earlier this year. 

Now is the time for Colorado home care providers to contact the state’s six congressional representatives for support of this or similar legislation in the House of Representatives. 

~ Encoding and electronic transmission of data is required only for Medicare and Medicaid patients receiving skilled care. For non-Medicare/non-Medicaid patients receiving skilled care, agencies must conduct the assessments and updates using OASIS, but will retain the assessments as part of the patient’s clinical record, rather than transmitting them. 
~ Collection, encoding or transmission of OASIS data has been delayed until after Spring 2000 for patients receiving only personal care or chore services, regardless of payer source, unless they are also receiving skilled care. 
~ Standard notification for all patients of their privacy rights is required upon admission to a home health agency. 
~ Efforts have been accelerated to encrypt data during transmission to provide more protection. 
~ Transmission of sensitive data on patient financial status has been eliminated. 
~ Personally identified data will no longer go to accrediting organizations. 
~ HCFA will limit the “routine uses” of OASIS data to other federal and state agencies. 
~ If a patient refuses to answer some questions that are part of the 
OASIS assessment, the agency may still deliver care as long as it completes and submits the OASIS assessment to the best of its ability, based on the clinician’s observations. 

Up to the minute OASIS information is available at the HCFA OASIS website at www.hcfa.gov/medicare/hsqb/oasis/oasishmp.htm. Samples of the Statement of Patient Privacy Rights, Privacy Act Statement-Health Care Records, and Notice About Privacy for Non-Medicare/Medicaid Patients and the updated HAVEN Version 2.0 can be downloaded from this site. The 500-page OASIS User’s Manual with updates can be ordered from HCAC by calling (303) 694-4728. 

1) Many staff members misunderstand what it takes to prove intent, a necessary component of fraud and abuse. Specifically, government enforcers must prove intent to show that providers engaged in fraud. 

Most providers certainly understand that if they submit claims for care that was never provided to patients, they had intent and have engaged in fraud. But staff members must also understand that court decisions say that if enforcers can prove that providers knew or should have known of a pattern of fraudulent conduct, enforcers may conclude that staff had intent. Other court decisions state that when providers show reckless disregard for a pattern of fraudulent conduct, regulators can show intent necessary to prove fraud. 

When staff members grasp these crucial standards, it is clear that they must become vigilant to prevent patterns of fraud and abuse. This is necessary to prevent government enforcers from concluding that they had intent necessary to prove fraud and/or abuse. 

2) Many staff members do not yet understand that every health care provider, regardless of position, is personally responsible for fraud and abuse compliance. It is extremely tempting to think that fraud and abuse compliance is management’s responsibility or the exclusive job of the CEO, COO or the agency’s Compliance Officer. 

On the contrary, the Office of the Inspector General (OIG) of the U.S. Dept. of Health and Human Services, the primary enforcer of fraud and abuse prohibitions, is quite clear that every provider has personal, 
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individual responsibility for fraud and abuse compliance. The OIG has taken this position because the OIG realizes that the problem of fraud and abuse will never be resolved until every provider takes individual responsibility for it. 

This point is reinforced by recent fraud charges brought against a home health agency in Florida called Amitan. Enforcers took action against both upper management and a number of individual field nurses allegedly involved in billing for visits that they never made, among other allegedly fraudulent activities. 

When practitioners understand these two basic points, they are well along the road to active participation in fraud and abuse compliance efforts. 

Home care providers must remember that fraud and abuse compliance is now a permanent part of the health care landscape across the nation. Compliance is not a “fad” that will blow over or disappear in a few months. Providers must be prepared to actively work to prevent or correct fraud and abuse for as long as they work in the healthcare industry. 

~ Elizabeth E. Hogue, Esq., Burtonsville, MD  (301) 421-0143.

The screening process is best provided by a multidisciplinary team of professionals in the field of nutrition support. Each team member should have a specific function to assist with the evaluation process. The team should be comprised of a physician, nurse, dietitian, pharmacist and a social worker. The dietitian’s role can be instrumental in terms of providing nutrition education to the various home care staff. 

To adequately screen a home care patient, one needs to determine nutritional risk levels. This process requires data from the medical record including information pertaining to: height, weight, diagnosis with other complications, physical examination and pertinent laboratory data.  Subjective information needs to be obtained directly from the patient. This includes: diet and weight history, food allergies and any intolerance as well as the use of medications or nutritional supplements. Patients should be categorized into one of three levels - low, moderate or high risk.  Once it is determined that a patient is at moderate or high nutritional risk, a more comprehensive assessment needs to be conducted to determine a care plan with outlined goals and objectives. 
 
Nutritional screening and assessment are crucial in determining the need for nutritional intervention for home care patients. A nutritional assessment is usually completed by a registered dietitian for high-risk patients. This assessment includes a care plan which can be monitored by the nursing staff. 

Although providing adequate nutrition is an important part of a patient’s care, nutrition is rarely the primary focus, but rather an adjunctive therapy. Therefore, it is paramount for home care agencies to have tools available to screen the nutritional status of their patients. Early, appropriate and aggressive nutritional intervention in the home care environment will help avoid the complications and costly effects of malnutrition. 

 ~ Leanne Logan, RD, CNSD, Enteral Program Manager, McKessonHBOC Red Line Extended Care, Denver  (303) 281-1938. 
 

_ Unintentional weight loss of 10 pounds in the last 6 months. 
_ Eating less than 2 meals per day. 
_ Mouth or teeth problems causing difficulty eating. 
_ Lack of financial resources to afford foods. 
_ Consuming greater than three or more alcoholic beverages each day. 
_ Depression resulting in eating alone or total lack of socializing. 
_ Unable to physically shop, cook or feed one’s self.

_ Biochemical and Hematological lab values (Reduction in serum albumin, 
       transferrin or pre-albumin) 
_ Change in intake and functional status 
_ Vitamin/Mineral deficiencies (e.g.. Folate, iron, zinc) 
_ Hydration status 
_ Skin condition and integrity (presence of decubitus ulcers or edema) 
_ Gastrointestinal status 
_ Medication profile - possible drug-food/nutrient interactions 
_ Appropriateness of medical nutritional therapy and response 
    (Tube feedings and Parenteral nutrition)

*In addition, the NSI has developed and published a three-tiered approach for determining nutritional risk. The NSI materials may be obtained from the Nutrition Screening Initiative at 2626 Pennsylvania Avenue, NW-Suite 301, Washington, DC 20037. These resources and other screening materials can assist home care providers with performing nutritional screening and intervention. 

(Ed. Note: This information has been provided to HCAC members as information only and in no way is to be inferred that HCAC recommends or endorses the contents.) 
 
 

The HCAC Board of Directors at its May meeting:

~ clarified the language in the board attendance policy; 
~ agreed that council meetings will be held at least one week prior to board meetings to allow enhanced preparation for board discussion. 

The course, which is intended to be an adjunct to an agency’s orientation program, orients the novice home care nurse to home care issues, regulations, documentation, accreditation and Medicare Conditions of Participation. The course covers the nurse’s role as case manager, working with the interdisciplinary team and patient advocacy issues. The 24-classroom-hour course is held quarterly on three consecutive Tuesdays. Teachers are long-time home care nurses Mary Beth Rensberger and Lou Anne Epperson. The next course will be held next on September 7, 14 and 21. 

According to Fragleasso, the group is presently working on developing triage criteria; e.g., classification of patients at different levels of risk. She expects that home care agencies will be  asked to identify patients who use ventilators, concentrators, bili lights, infusion pumps with critical medications, suctioning equipment and any other life-sustaining/critical equipment that relies on electric power. Several HCAC members are providing feedback about the triage criteria which are still in draft form. 

Fragleasso reminds agencies that efforts to prepare for Y2K should blend well with plans for any disaster. She said, Y2K presents an opportunity to prepare or review the agency’s disaster management plan and general preparedness procedures. As always, it is the responsibility of home care agencies to have such a plan in place and to work with each patient to assure preparedness for the continuation of treatment in the case of any type of disaster. For example, Fragleasso said, options must be identified and in place if there is any reason a home 
care staff member could not get to a client because of access problems caused by a natural disaster such as a blizzard or flood or a man-made disaster such as Y2K. 

~ Alys Novak, member of PR Project Team, Communications/ 
Technology Council, Visiting Nurse Corp of Colorado, Denver